With reference to examples, evaluate the success or otherwise of urban regeneration schemes in combating the causes and consequences of urban decline free essay sample

Regarding models, assess the achievement or in any case of urban recovery conspires in fighting the causes and results of urban decrease. (40 imprints) Urban decay can be characterized as the radical decrease of a city into illness and dilapidation. It is typically described by expanded joblessness, elimination, deindustrialization, expanded wrongdoing and political disappointment. In addition to the fact that it causes these issues it can make the zone look ugly †subsequently less individuals being allured to the region. This would then be able to prompt an endless loop. The reasons for these variables, which at last reason urban decrease, can be: taught laborers hold moving to suburbia to keep away from wrongdoing, poor schools, charges and racial strains. These organizations likewise find that building new offices in suburbia is a lot less expensive than renovating old structures for their necessities. There are numerous motivations to move out of the city yet just a couple of motivations to remain. We will compose a custom exposition test on Concerning models, assess the achievement or in any case of urban recovery plots in battling the causes and outcomes of urban decrease or then again any comparative point explicitly for you Don't WasteYour Time Recruit WRITER Just 13.90/page At the point when a city or a urban zone sinks into decay, the gathering has the decision to recover the territory to tempt individuals over into the region. At the point when recovery is considered with regards to ‘urban,’ it includes the resurrection or reestablishment of urban regions and settlements. Urban recovery is essentially worried about recovering urban communities and early/inward ring rural areas confronting times of decrease. The term urban recovery covers everything from making attractive homes in downtown areas to finding new uses for our formal mechanical heartlands. While recovering a zone the accompanying standards are about consistently followed: coordination between different segments, making a comprehensive vision, recovering individuals instead of a spot, making organizations over all degrees of government, building open segment limit and authority, and drawing in the nearby network in the arranging procedure. One approach to recover a territory is by property-drove recovery. Property-drove recovery plans include constructing or improving property in the region to change its picture and improve the neighborhood condition. This was especially effective in the London Docklands. During the nineteenth century, London’s port was one of the busiest on the planet and stockrooms, businesses and high thickness and low quality lodging and so forth encompassed the docks. Before the finish of the 1950s, there was a huge decay with a significant number of the docks neglected and deserted; there were additionally numerous positions lost and poor day to day environments despite everything remaining. Access to the remainder of London was poor with slender streets, which were vigorously blocked, and an absence of open vehicle was turning into an immense issue. While the LDDC was liable for the arranging and redevelopment of the Docklands territories, other association have additionally been engaged with the redevelopment procedure, these included: ? landowners, architects and engineers, financial specialists, neighborhood individuals and focal government. In docklands, monetary recovery was viewed as a need and the administration felt that property engineers would realize how to create land in manners that would pull in organizations. Employments would be makes, and riches, it was contended would ‘trickle down’ to more unfortunate networks. It concentrated on the production of business the recovery of existing lodging stock and the making of new moderate lodging. The administration activity likewise bolstered urban recovery: tax reductions, deregulation and furthermore working hours could be changed relying upon the business. The Environmental Regeneration? examined effective with a system of passerby and cycle courses through the territory with access to the stream and dock edge through waterside walkways? , making of person on foot spans? what's more, making of new open spaces (150ha)?. There was likewise a water based Ecology Park and Londons first fledgling asylum at East India Dock Basin one of 17 preservation zones set up? , planting of 200,000 trees (the zone has now gotten numerous honors for engineering, protection and arranging). The Economic Regeneration was likewise extremely fruitful. Joblessness had tumbled from 14% to 7. 4% with a multiplying in work and quantities of organizations; there was a ‘transport revolution’ opening of the Docklands Light Railway in 1987 presently conveying 35,000 travelers per week;? ?7. 7 billion in private area venture? 2,700 organizations exchanging? ; major new streets including connection to the M11? ; working of the City Airport in the previous Royal Docks (500,000+ travelers a year)? ; fascination of money related and cutting edge firms; TV studios and papers, for example, The Guardian presently have workplaces in the renowned Canary Wharf business complex.

Effectiveness of Brand Extension in Personal Care Product: A Case Study on Dove of Unilever

Brand is seen to be in significant impalpable resource for organization which gives organization a front line in item advertise through situating in purchaser mind. To use on achievement of brand, organizations go for brand augmentation which is offering diverse new item in a similar brand name.Such brand procedure is expected to be sought after to spare expense of propelling new brand, to limit danger of brand disappointment and to use on accomplishment of existing brand. Association who are in close to home consideration item business frequently go for such brand expansion regarding brand as their helps where they attempt to use on their image value by propelling new items under effectively settled brand names (Vanitha et al, 2001). There are numerous components that characterize the viability and achievement of brand augmentation in close to home consideration products.Perceived Quality of Parent Brand, the general significance of attack of brand with customer attributes and cruci al brand are significant variable which decide brand achievement (Park, et al, 1991). Past those variables, in the event of individual consideration brand augmentation, media arranging, brand advancement and brand the board and open connection to impart the brand are viewed as compelling in assessing the achievement of brand extension.This look into work is examined to assess the viability of brand expansion system in close to home consideration items by and large and brand augmentation technique of Dove brand of Unilever. The report will expound whether brand expansion system of Dove was fruitful one considering the variable referenced above.The report is readied dependent on customers’ reactions gathered through study and perceptions of marking master to survey such viability. The turnover from items propelled under brand augmentation procedure will be needy variable that will be assessed against Brand Campaign, Media Planning, Brand Development and Brand Management, and Pu blic Relation Strategy of brand. The investigation will be founded on Dove brand of Unilever which will layout how organization changes marking procedure with advancement of Dove brand.1.1 Background of the OrganizationUnilever’s venture as business association began at 1872 as margarine business. In 1890, the organization was named as Lever Brothers Limited. In 1930 Margarine Unie (Netherland) and Lever Brothers Limited (UK) consolidated and renamed as Unilever Limited. Serving 2 billion clients around the world, the organization is accomplishing yearly turnover of â‚ ¬51 billion out of 2012 (Unilever, 2013). The organization sells its items across 190 nations where developing business sector currently means 55% of the business. The organization have arrangement of 14 money bovine brand that are creating â‚ ¬ 1 billion deals around the world. The organization utilizes around 173,000 individuals around the world (Unilever PLC. 2013a).The arrangement of classifications s hows that around 35% of income originates from Suvoury, Dressing and spread, trailed by Personal Care which is about 28%, Home Care which is 18% and food and refreshment fragment covers 19%. Unilever has an arrangement of 400 brands among which some are world biggest regarding producing thoughts. With a benefit base of â‚ ¬46.16 billion, the organization has working benefit of about â‚ ¬7 billion (Unilever PLC. 2013b).Dove is a billion brand of Unilever which is creating yearly income of â‚ ¬2.5 billion every year in 80 nations. Bird Brand was propelled in 1957 as choice to cleanser to mind of dry skin. Since 1980 numerous item is propelled under Dove brand going from body-wash, antiperspirants, body creams, facial chemicals, to shampoos and conditioners through brand expansion (Unilever PLC, 2013). Unilever terms Dove as a brand with a purpose.1.2 Rational of the StudyBrand is seen to be significant factor to situate item in consumers’ mind. A brand picture has beco me a striking asset and basic achievement variables of rivalry which gives firm upper hand in item showcase. To use on such serious edge firms now and again takes system of brand augmentation to use the achievement of existing brand to improve and justified interest in brand. In any case, such brand expansion created blended outcome regarding adequacy or profit for brand augmentation because of brand fit with item propelled, usefulness of brand and customer disposition to acknowledge new item (Kim and Deborah, 2008).To change buyer observation on the ground of useful advantage of brand, association has toâ reshuffle its marking correspondence to reposition brand in purchaser mind which convey a more extensive perspective on brand instead of utilitarian advantages. The adequacy of such brand augmentation relies upon how firm create brand, assemble brand and plan media to convey the brand and keep up open connection to draw in partners (Bottomley and Stephen, 2001). Advancement of Br anding effort is another significant parameter in such manner. The examination will assess the brand expansion system of Dove through looking at through changed elements referenced only above to legitimize brand augmentation technique in Personal consideration item category.1.3 Business Research QuestionsThe following exploration question will be intended to lead the investigation. what is the brand expansion technique of FMCG organization in close to home consideration items What are the variables that influence brand augmentation methodology of a set up brand in the event of individual consideration items How brand battle, media arranging, client disposition, brand advancement and the executives, open connection reshuffle brand expansion procedure if there should arise an occurrence of Dove brand of Unilever What is the measurable perceptions of impact of parts of brand augmentation in situating item in shopper brand1.4 Research objectiveEvery investigate is led in light of satisf action of certain destinations. Those destinations convince the specialist to seek after research in this field of study to enhance the analyst scholarly perception. Coming up next are the examination target of the investigation which rouses the specialist to seek after this exploration. To survey brand expansion system in close to home consideration productTo follow out the reasons that assumes key job in creating brand augmentations technique in close to home consideration items To investigate the fundamentally achievement factors that decides the adequacy of brand expansion methodology in close to home consideration items To remove out how brand crusade, media arranging, client demeanor, brand improvement and the board, open connection assumed job in influencing accomplishment of brand augmentation of Dove brand of Unilever To assess the result of the examination through measurable test to approve the discoveries of the examination on rand augmentation procedure of Dove To propos e fitting and explicit proposals and to give end along referencing the extent of future extent of study.2.0 Literature ReviewLiterature audit is significant piece of any believable research and it gives the exploration a chance to survey comparative and related past research to take proficient knowledge to structure their investigation. The second section of the examination will cover the writing audit identified with title of the exploration. The accompanying segments will be secured by this chapter.2.1 BrandBrand can be characterized as name, tern, sign, image or structure, or a blend of them proposed to recognize the merchandise and enterprises of one dealer or gathering of venders and to separate them from those of different merchants (AMA, 2011).2.2 Brand Extension and Types of Brand ExtensionBrand expansion is methodology of propelling and selling new item under a built up brand name of other existing items to convince customer’s observation with accomplishment of exist ing items (Monga and Deborah, 2007). Expansion can be portrayed as methodology to sell new items without building up another brand of the organization (Chen and Liu, 2004).There are two kinds of brand augmentation for the most part utilized in marking procedure. The accompanying chart is explaining such sorts of brand extension.2.3 The Reasons of Brand ExtensionThere are rationales why association goes with brand augmentation as opposed to propelling new brand for each new item. The most persuasive contentions are diminishing danger and cost of propelling new items, expanding deals and benefit of the organization and having the option to ask an excellent value (Alokparna and Zeynep, 2012). The other explanation incorporates increment brand mindfulness and saw brand estimation of the organization (Smith and Park, 1992).2.4 Brand Extension in Personal Care productsBrand augmentation in close to home consideration item is more predominant than other typesâ of item because of homogenei ty in item nature and correspondence of basic observation to the shoppers. From Unilever to P&G everybody follows brand augmentation system pretty much in their own item portfolio (Xie, 2008).2.5 Factors that Determines the achievement of Brand Extension strategyVarious factors brand expansion methodology of individual consideration items. The given case plot the accompanying components that were viewed as persuasive in influencing brand expansion technique to Dove from cleanser to other individual consideration products2.5.1 Branding CampaignBranding effort is significant parameter to change client discernment from a smaller perspective to more extensive perspective. Prior Dove is viewed as a purging cream or saturating cream (Tom et al, 2012). At whatever point Unilever proposed to impart Dove as Masterbrand, it reshuffles its crusading procedure to convey Dove brand battle as â€Å"Campaign for Real Beauty† (Deighton, 2008). The case delivered the accompanying discussi on.2.5.2 Branding to Change Customer AttitudeSuccessful brand augmentation system change client disposition to the kindness of new item propelled under built up item class. In Dove case, the marking effort rethinks the thought of excellence to the ladies of the world by saying that each lady has genuine magnificence, which is simply not characterized by size, skin or age.The brand characterizes excellence as capacity of confidence, feeling prevalence a

Describing the Five Senses in a Compelling Writing Style

Describing the Five Senses in a Compelling Writing StyleReading is one of the most productive forms of learning, and so is the essay that uses the five senses. Describing an experience using the five senses involves employing the mind, eyes, ears, nose, mouth, and hand. When these senses are used, the writing is more descriptive and should therefore be more pleasing to the reader.Hearing is the first sense to be used. This includes detecting sound. The following two senses are to be used if possible. When the senses have been used in a poem, for example, the description will have more depth.If you are only able to use one or two senses, you should concentrate on this and be sure that the description is comprehensive enough to fill the five senses. This will make the article more engaging. The more descriptive, the better.When describing the senses, write with the human voice. When using only one, it will be difficult to describe correctly. When the other senses are involved, it becom es easier. Consider using metaphors to describe the sounds. For example, 'the sound of wind blowing across water.'In describing the smell of a person, you should be able to smell the scent of their clothing. You should also be able to hear the sound of their breath. When considering the taste of a person, you should be able to see the taste of food and/or drink. Writing in the five senses requires that you pay attention to detail. You should also think carefully about the effects the smell, sight, and sound will have on the reader.Describing the sounds of the environment requires the use of the eyes. At the same time, the ear is important aswell. It is important to know whether the person is speaking to you. A reader will react to the sounds you hear. The sounds should be a key component of the writing.A great descriptive essay is likely to use all five senses to a greater or lesser degree. This is especially important when the subject is personal or sensitive. All the senses should be engaged in order to be able to understand the author's words. A good example is that of a picture in a sentence. The picture is a strong part of the description, but the full description is composed of the senses mentioned above.Even though the five senses are sometimes described as being limited, they are very powerful when employed properly. The five senses help to describe the environment, individuals, sounds, feelings, and sights and to give an overall impression of the subject.

The Meaning of Leadership - 2491 Words

â€Å"Leadership is a process whereby an individual influences a group of individuals to achieve a common goal.† (Northouse) I use to believe that leadership shows the confidence that many people do not portray, because my thoughts were that leadership was a group of people who stand up for the things that they believe. After an extensive study on the meaning of leadership, I have come to find that there is no way to specifically define the meaning of leadership, but there are ways to grasp a better understanding of what the aggregate meanings entail. The big questions that we are faced with are these; how is leadership approached in life, when is it practiced and needed, and who are some leaders in history that portray great leadership skills.†¦show more content†¦The next subject that I will discuss is when leadership is practiced, and needed. According to Northouse research in administration as well as his own observation in the workplace, leadership takes place ba sed on personal skills: technical, human, and conceptual. Technical Skill includes those who are able to use different tools and techniques in different areas of expertise. This type of leadership skill can be used in computer software companies, accounting firms, architecture, technology design, programming, and many other areas in the workplace. Technical skills are focused more in the middle and lower levels of management, and less in the upper levels for chief executives, CEO’s, and senior officers. Human skill is the ability to work with people, which is quite different from working with technical things. Human skills help with workers, and superiors and create a cooperative work place in which little conflicts take place, this meaning that the leader with human skills are able to look at all angles of perspective and easily mold everyone’s ideas together to be a fair environment for everyone. Those with the human skill incorporate many other leadership skills because they create a comfortable environment with integrity and encouragement as well as including of others. An eminent leader who isShow MoreRelatedLeadership : The Meaning And The Definition2024 Words   |  9 PagesLeadership - The Meaning and the Definition By Shaun Swilling | Submitted On November 07, 2014 Recommend Article Article Comments Print Article Share this article on Facebook Share this article on Twitter Share this article on Google+ Share this article on Linkedin Share this article on StumbleUpon Share this article on Delicious Share this article on Digg Share this article on Reddit Share this article on Pinterest Expert Author Shaun Swilling Leadership is the foundation on which countriesRead MoreThe True Meaning of Nursing Leadership Essay2314 Words   |  10 PagesThe True Meaning of Nursing Leadership By understanding the differences between the broad spectrums of leadership and the underlying styles that can be used to better facilitate the care setting; we can comprehend what nursing leadership truly is. 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Symptoms And Symptoms Of Bipolar Disorder - 1890 Words

Bipolar Disorder By: Aaron Montez Psychology 201 Abstract Bipolar Disorder can affect men or women at any stage of their life. The disorder can be triggered by a traumatic incident or inherited and can cause wide mood swings. These mood swings will go from the feeling of euphoria, that can last for several days, to severe depression that can last for weeks. Each episode can be mild or severe depending on the situation. Medication can be used to help the patient control the symptoms. Most effectively is the proper lifestyle changes that a person must adapt to manage their symptoms and prevent severe swings in their behavior. Having a close friend or relative that is trained in detecting the oncoming episode is essential to helping the patient manage their disorder. It is imperative for the patient to maintain and continue taking medications as prescribed. 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The Reflection Of The Dance - 752 Words

The Dance White. Everything is white in hospitals. I guess it is because it makes the place feel clean. I have been in the hospital as a visitor enough for a lifetime, though I have never grown used to the aura. I do not think anyone will. When I first walk in, my nose burns from the sterility in the air. It takes my eyes a minute to adjust to the harshness of the fluorescent lights. It is quite ironically humorous, the staff, in a constant rush, the loved ones, sluggish from sorrow and lack of sleep, the patients, who carry a host of emotions with them. They all complement each other. Though it is ignorant of the world outside its walls, the hospital is mindful of its occupants. I have always been fascinated by the delicate dance of the hospital, how doctors, surgeons, and nurses have to coerce parents in to taking risks in order to save a life, and how they have to be the bearers of by news. Despite the amount of deaths and tragedies, the dance never stops, the partners just change. It is October and the coldness of outside matches the icy interior of the hospital. I have been in the surgical waiting room for three out of the ten hours, and I already feel antsy. I have sat in every possibly comfortable position I could think of in the cheaply upholstered chairs. So I decided to roam the halls. As I walk down the halls I take it all in. The children pushing each other in their wheel chairs, smiling though their cannulas and IVs, the babies that are cloakedShow MoreRelatedDance Reflection1037 Words   |  5 PagesDance works as its own form of communication, which enhances comprehension and content retention. â€Å"We participate in a special kind of human communication in which we speak the same language even though no words are exchanged† (Zakkai, 1997, p.15). Different modalities create more opportunities for broadened understanding. Dance forces students and teachers to find the core meaning within a subject area. 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What I have found is that improvisation is indeed when a dancer dances in an unplanned state, but improvisation is not thoughtless. In fact, when a dancer improvises although the movement is somewhat random, as the dancer improvises their minds are constantly going into overdrive thinking about what they are going toRead MoreDance Reflection Paper761 Words   |  4 Pageshealthy dancer was the Balanchine dancer, skinny, long, and flexible. I think that is a mentality that many dancers suffer with. Outside of the dance studio, peopl e would also comment that I looked skinny and healthy which reinforced my idea that skinny is better and the skinnier I was the more people would compliment me. It wasn’t until I began explore modern dance that my perception of a â€Å"healthy† dancer shifted. â€Å"Strong was the new skinny†, according to my modern teacher. 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It provides fresh insight into the field and allows us to expand our knowledge on our given modality and view it through a different lens. These past weeks exposed me to new ways of going about dance/movement therapyRead MoreEssay about dance class reflection792 Words   |  4 Pagesï » ¿Dance Class Reflection Over the course of the semester, I have learned about different types of dances including hip hop, dance hall, and contemporary, Bhangra, street jazz, Latin, zumba and more. In the beginning, I believed that I danced well and dance was easy to do but once I figured out how much effort, practice, coordination, and preparation for a dance, I thought differently. Dance is all about expressing your emotions by using your body, having fun, gaining strength in my muscles and developingRead MoreReflection Of West African Dance1424 Words   |  6 Pagesoverall understanding of West-African dance alone. 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Authentic Learning for Young Gifted Children

Question: Describe about the Authentic Learning for Young Gifted Children. Answer: Context: According to (Gulikers, Bastiaens and Martens, 2005), the teachings regarding the authentic learning environment leads to larger performance and also helps in improving the intrinsic motivation of the students. Authentic learning environment offers a platform for the students to grow their knowledge and skills that would be useful in their life. According to (Reid and Romanoff, 2016), in the extensive Mecklenburg school, thousands of children are identified as gifted and are also tackling the real world problems. The reflective and authentic performances assessments are done by the teachers, students and community members in order to show the students that they understand truly. The gifted students have extraordinary problem solving skills in intelligences. The formats for gifted program are widely varied at 83 elementary schools. Early identification along with intervention is necessary for their growth and development. There is no formal consensus on the definition of young gifted children (Sternberg Davidson, 2005), yet there are some traits that all young gifted children share with. Young gifted children usually display significant advancement in various domains such as superior memory, creativity, strong reasoning, strong visual-spatial capacity, early language and intensive vocabulary, vivid imagination, independent investigations, desire to search for personal identity and social connections, capacity of analysis, synthesis and evaluation by using higher order thinking (Gardner; 1999; Harrison, 2004) though a single gifted child may not demonstrate all of these characteristics. They tend to display great curiosity and a variety of interests with an inquisitive mind to learn and to explore. They show strong analytical and meta-cognitive skills, enjoying problem solving, preferring complex tasks, and actively engaging in planning, monitoring and evaluating in the learning process (Steiner Carr, 2003; Kanevsky, 2011). As per the research undertaken by Adel son, McCoach, Gavin (2012), the set of courses and the instructional changes that are depicted in this case helps in modifications with emphasizing on the steps which are undertaken for the purpose of employing the open-ended problems for the purpose of creating the initial stimulus for the purpose of learning. The effectiveness seems to be developed with focusing on the field testing related to the student creativity and productivity, personal and social development of student and the students self-efficacy (Sousa, D., 2009). Authentic learning will allow the students experiment themselves and giving an opportunity to fulfil their curiosity. All this poses a challenge to the teaching practices in the traditional classroom where students play a passive role and focus on abstract and decontextualized concepts of little apparent relevance, (Hill Smith 2005,p. 22) and where limited opportunities are provided for the children to plan their learning activities, to collaborate with team members and to reflect on their own learning process. Students are not reduced to mere collectors of facts and procedures, but actively construct knowledge connected to the real-world matters and problems of their interest (Eiserman, Lai, Rushton, 2015). In the authentic activities, learners are given opportunities to collaborate with their team members, develop higher-order thinking skills, apply interdisciplinary knowledge to produce beyond domain-specific learning outcomes, integrate assessments and reflections seamlessly within the learning activities, use different resources and view the tasks form different perspectives, which can lead to competing solutions and diversified outcomes(Herrington, et al. 2002). As refined and further developed by Hill and Smith (2005), the Theory of Authentic Learning is characteristic of 10 linked factors: mediation, embodiment, distribution, situations, motivation, multiple illiteracies, identity, career planning, human relationships and teac hing attitudes. In such an environment, culture, cognitive and affective, context and collaboration are interrelated; curriculum, instruction and assessment interact with each other and teachers guide students and create for them a variety of authentic learning opportunities to connect them to the complex real world (Kuo, Maker, Su, Hu, 2010). As per the analysis made by the Van Tassel-Baska, Feng, Evans, (2007), depicts the changes of various perceptions which are depicted for monitoring the gifted programs in order to create an open world. The numerous dynamic tests are created in this research for specifying the aspects of the particular curriculum and the non verbal tasks for the establishment of cognitive changing ability is generated in order to increase the general capacity of the students (VanTassel-Baska, Feng, Evans, 2007). Purpose and Research Questions: The purpose of the study is to explore authentic learning approach applied for the education of young gifted children. The research questions are as follows: What are the needs of the young gifted children? What curriculum design can be adopted to help to satisfy the needs of these young gifted children? How does authentic learning theory function to meet the needs of the young gifted children and the corresponding curriculum design? Theoretical Framework A constructivist epistemology will be applied to view learning as an active process in which students are engaged in the construction of meaning and knowledge in the authentic learning environment and teachers foster motivated students with developmental appropriate curricular and provision for the young gifted children. Essay Page 2 Methodologies Qualitative methodologies will be applied to the research of exploring the topic of authentic learning for the young gifted children in depth and in detail and to benefit from the fruitfulness and often greater depth of understanding we can derive from qualitative procedures. (Berg, 2007, p2). A portfolio of two models will be established based on an extensive literature review and further modified based on on-going research observations and results to address two interrelated aspects of the research: an authentic learning model and a teacher development model. The 10 linked factors from the Theory of Authentic Learning by Hill and Smith (2005) will be incorporated into the authentic learning model and the hermeneutics method will be applied to further reframe it in the context of the young gifted children. Two classes of gifted children from 5-6 years old as well as their teachers will form the exemplars of the research. Triangulation will be applied by multiple stakeholders, data a nd methodological sources to achieve credibility and confirm ability of the date collected. The evidence can be teacher observation and notes in classes, research team participant observation, videotapes of students, in-depth interview with teachers and students, a survey with parents, student products, student weekly reports, and peer/self evaluation questionnaires. The teachers participation will be documented and evaluated, which will provide feedback to the teacher development model to strengthen their skills so as to ensure dependability and transferability of the data and research(VanTassel-Baska, 2013). The research project is viewed from a developmental perspective; the teacher acts like the action researcher and all stakeholders feedback will be incorporated into the two models on an on-going basis to build up developmental appropriate practices. Due to the young age of the research subjects, the research will be conducted under a full ethical review. The researcher will collect information and data from the teachers, people of school boards and principals. The researcher will conduct interview with them in order to determine and analyze their perspectives and perception towards Authentic learning for the young children (Flick, 2009). With the help of qualitative analysis, the researcher will be able to understand their views towards Authentic learning for young children as well as the necessary steps that has been taken for the development of authentic learning (Myers, G, T., 2016). It will also help to evaluate the learning model and teacher development model that will be adopted for the development of young gifted children. The research will apply discursive approach to explore their efficiency level while interacting with the participants. The focus of the strategy will vary from the use of language at micro level to social processes, practices and experiences of the participants at the macro level. The discursive research wil l help to determine the language and culture of the participants which is important during the interview process (Scruggs and Mastropieri, 2006). The documentary analysis is the social research method which is an important tool for research to analyze and interpret information and data. The information and data collected from the participants will be analyzed with the help of documentary analysis. The interview process will help to gather data and information about teacher development model and authentic learning model (ihmgwalior, 2016). Contribution to Advancement of Knowledge: Authentic learning approach provides an effective and efficient solution to address the concerns and characteristics of the education of the young gifted children. Authentic learning has been addressed in the settings of higher education, secondary education, and technology education and for children with academic abilities at the lower end of the spectrum, yet very little empirical ( Note: Is it suitable to use this word if I use qualitative methodology in this research?) or theoretical research has been conducted in the field of giftedness education(Williams, 2009). And up till now no research has been done regarding how the authentic learning approach functions in the setting of young gifted children, which makes this study a pioneer in the research area, endowing it with far reaching meanings and significance. Background and Experience: As a first year PhD student, I am currently taking courses such as Curriculum Design with my supervisor, whose expertise and research strength include qualitative methodology, theory of authentic learning, multiple intelligences, problem/project-based learning and curriculum theory and development. I have a diversified, multi-disciplinary and interdisciplinary background in both the academic and professional domains at the higher level in education, language and literature, management, project management, culture and technology with several Masters degrees and working experiences in the federal government and educational sectors. My experience of being a gifted student myself and mom of a young gifted child also provides me with some insight and perceptions in the research area. The researcher will conduct documentary analysis and data collection process in order to determine and evaluate the research topic. Bibliography and Citations Adelson, J., McCoach, D., Gavin, M. (2012). Examining the Effects of Gifted Programming in Mathematics and Reading Using the ECLS-K.Gifted Child Quarterly,56(1), 25-39. Al-Hroub, A. (2011). Developing Assessment Profiles for Mathematically Gifted Children with Learning Difficulties at Three Schools in Cambridgeshire, England.Journal For The Education Of The Gifted,34(1), 7-44. Berg, Bruce L. (2007). Qualitative Research Methods for the Social Sciences, Sixth Edition, Pearson Education Inc. Dean, G. (2008).English for gifted and talented students, 11-18. London: Sage. Eiserman, J., Lai, H., Rushton, C. (2015). Drawing out understanding: Arts-based learning and gifted children.Gifted Education International. Flick, U. (2009).An introduction to qualitative research. Los Angeles: Sage Publications. Gardner, H. (1999). Intelligence Reframed: Multiple Intelligences for the 21st Century, Basic Books, New York. Gulikers, J., Bastiaens, T. and Martens, R. (2005). The surplus value of an authentic learning environment.Computers In Human Behavior,21(3), 509-521. doi:10.1016/j.chb.2004.10.028 Harrison, C. (2004). Giftedness in Early Childhood: The Search for Complexity and Connection, Roeper Review, 25, 78-84. Herrington, J., Oliver, R., Reeves, T. C. (2002). Patterns of Engagement in Authentic Online Learning Environments, Australian Journal of Educational Technology, 19, 59-71. Hill, A.M. Smith, H. A. (2005). Research in Purpose and Value for the Study of Technology in Secondary Schools: A Theory of Authentic Learning, International Journal of Technology and Design Education15, 19-32. Kanevsky, L. (2011). Deferential Differentiation: What Types of Differentiation Do Students Want?, Gifted Child Quarterly, 55, 279299. Kuo, C., Maker, J., Su, F., Hu, C. (2010). Identifying young gifted children and cultivating problem solving abilities and multiple intelligences.Learning And Individual Differences,20(4), 365-379. Reid, C. and Romanoff, B. (2016). Repr 21 October 1997, https://web.csulb.edu/~arezaei/ETEC444/discussion/assessing%20gifted.pdf Scruggs, T. and Mastropieri, M. (2006).Applications of research methodology. Amsterdam: Elsevier JAI. Sousa, D. (2009).How the gifted brain learns. Thousand Oaks, Calif.: Corwin. Stein, G. Poole, P. (1997). Meeting the Interests and Needs of Gifted Children: A Strategy for Teaching and Learning, Early Child Development and Care, 130, 15-19. Steiner, H. H. Carr, M. (2003).Cognitive Development in Gifted Children: Toward a More Precise Understanding of Emerging Differences in Intelligence,EducationalPsychologyReview, 15, 215246. Sternberg, R.J. Davidson, J. E. (2005). Conceptions of Giftedness, 2nd Ed, Cambridge University Press, Cambridge, UK. VanTassel-Baska, J. (2013). Performance-Based Assessment: The Road to Authentic Learning for the Gifted.Gifted Child Today,37(1), 41-47. VanTassel-Baska, J., Feng, A., Evans, B. (2007). Patterns of Identification and Performance Among Gifted Students Identified Through Performance Tasks: A Three-Year Analysis.Gifted Child Quarterly,51(3), 218-231. Williams, C. (2009). Interactive Writing as Informed Assessment with Highly Capable Young Children.Gifted Education International,25(1), 14-21. ihmgwalior,. (2016).RESEARCH METHODOLOGY.www.ihmgwalior.net. Retrieved 25 October 2016, from https://www.ihmgwalior.net/pdf/research_methodology.pdf Myers, G, T.,. (2016).Research Methodology by Numbers a teaching tool.Ejbrm.com. Retrieved 25 October 2016, from https://www.ejbrm.com/issue/download.html?idArticle=258

You Are What You Eat Essays - Diets, Intentional Living,

You Are What You Eat You are what you eat, goes a famous saying. And if that is truly the case, then a lot of Americans would appear to be unhealthy, chemically treated, commercially raised slabs of animal flesh. And while that is not a particularly pleasant thought, it is nonetheless an description of the typical American omnivore who survives on the consumption of Big Macs and steak fajitas. But there are individuals who do not follow this American norm and have altered their diets so that they do not consume any meat. These people are vegetarians, and they are the new breed of healthy Americans who refuse to poison themselves with fats, cholesterol, and the other harmful additives that come from meat. And while once thought to be a movement that would never gain much momentum, it has nonetheless moved itself to the forefront of Americans' healthy diets. The word vegetarian, used to describe the diets of people who do not consume animal flesh, was not used until around the mid-1800s. The concept of vegetarianism, however, dates back much further. The Greek philosopher Pythagoras, considered by many to be the father of vegetarianism, encouraged a non-meat diet among his followers as a diet that was the most natural and healthful (Messina 3). A vegetarian diet excludes the consumption of meat, and can be exercised by people for a number of reasons. The largest majority of individuals chose vegetarianism for health related reasons. For example, someone with an ulcer might be prescribed a strict diet of vegetables in order to promote the healing process. Or someone with a dangerously high level of cholesterol might be advised to follow a vegetarian diet to lower his or her fat and cholesterol intake. The immorality of consuming animal flesh is another argument touted by a smaller group of vegetarians. R.G. Frey describes this moral argument for vegetarianism and the effect that meat eating might have on the character of humans: Some people have come to believe and fear that, in the suffering and killing which occurs in commercial farming, we demean ourselves, coarsen our sensitivities, dull our feelings of sympathy with our fellow creatures, and so begin the descent down the slippery slope of torture and death, to a point where it becomes easier for us to contemplate and carry out the torture and killing of human beings. (20) This moral argument for vegetarianism is also noted by John Robbins who states that the suffering these animals undergo has become so extreme that to partake of food from these creatures is to partake unknowingly of the abject misery that has been their lives(14). But whatever the reasons behind a person's choice to be a vegetarian, it is important to understand the different diets that individual vegetarians can choose. In the widest sense of the word, a vegetarian diet is a diet that is made up of grains, vegetables and fruit, but does not include any animal flesh, such as fish, pork, poultry, or beef. But beyond these standards, there are many variations of diet that occur within the world of vegetarianism. The first, and most prominent, category of vegetarianism is a lacto-ovo vegetarian. Mark Messina describes a lact-ovo diet as ...a vegetarian diet (that) includes dairy products and eggs but no animal flesh(7). This means that there is consumption of animal byproducts, such as milk, eggs, or honey, but there is no consumption of animal flesh. Another variation is the lacto-vegetarian diet that allows the consumption of milk and other milk products, but does not include the consumption of eggs. And like all vegetarians, these two groups do not consume fish, poultry, or meat (Messina 7). Another category that vegetarians can fall into are vegans. The vegan diet is by far the most strict of all the vegetarian diets. According to Mark Messina, Vegans avoid meat, fish, poultry, dairy, and eggs. There are many other foods that may not be acceptable to many vegans, however. Foods that involve animal processing to any degree are often avoided(11). This means that vegans can consume no foods containing animal byproducts, such as milk, eggs, or honey. Being a vegan often dictates an animal friendly lifestyle that, aside from not eating anything that came from an animal, also abstains from buying or using products that were tested on animals or are made from animal hairs or skin, such as leather shoes or belts (Messina 11). A common misconception of vegetarians is that they are all a

Make your University Admissions Essay Compelling

Make your University Admissions Essay Compelling Make your University Admissions Essay Compelling A compelling university admissions essay can be the difference between acceptance and rejection. Grades are an important part of your application, but they are not the only key component. Your writing will help set you apart from other applicants with similar scores. Knowing how to write an essay will leave a good impression. Think of it as an opportunity to show admissions officers what qualities you have that would make you a good candidate for their school. You have a unique background and set of experiences; your university admissions essay is a way to share all that with prospective schools. The trick is to write a thoughtful, personal paper about a topic that matters to you. Many applicants try too hard to sound smart, or write about topics they don’t care about to look impressive. All you have to do is show yourself as thoughtful and motivated, and that will demonstrate that you have something to add to a class. Use these tips to help craft a strong essay that highlights what you have to offer: Read the instructions In all the excitement, you might forget to thoroughly heed the instructions. Follow the application directions to the letter. Failing to comply with guidelines could lead admissions officers to assume you wouldn’t follow the program’s directions. Stick to page and word count limits. The idea is to organize your thoughts according to the rules. Organize your thoughts Start by brainstorming. Take a piece of paper and jot down ideas. Do some research on different topics and ideas that you might find interesting. Then consider which ideas could combine with one another. For example, you can compare and contrast different ideas. Write a rough outline. Think about how long each paragraph should be to express your ideas clearly. Finally, create a schedule as a guide for how much time to devote to your work. Be controversial Many applicants submit bland, safe essays that don’t take a stand on anything. Discussing politics or religion can be a valid approach! Remember to stay balanced and thoughtful, regardless of your opinion. Present your views on the subject, but be fair and logical. Give reasons to support your position. â€Å"Avoid speechifying.† Higher education is the place for discussion of ideas. Your essay is a tool to present your ideas to an interested panel. Some people look for diversity of ideas, so consider sharing some of yours. Avoid using cliches Looking at other essays as research is generally an excellent idea. However, be wary of other writers’ influence. Precise word choices and unique phrases will help your paper stand out from the crowd. Review your work and delete any â€Å"old hat† statements. Give admissions something that’s all yours and make them take notice. Be careful with humour Jokes can be an excellent way to get yourself noticedbut use this technique carefully. Your idea of â€Å"funny† may differ from that of an admissions’ officer. Avoid one-liners, limericks, and off-colour humour. They may be perceived as unprofessional. Show, don’t tell Avoid simply stating facts and ideas. Admissions officers are more concerned with your perspective on events than with the events themselves. Include specific details and examples. For example, don’t merely mention extracurricular activities. Describe how they made you feel, and what you learned from participating in them. The officers don’t know you personally. Use your words to paint a picture of who you are and what you can contribute to the college or university. Know your vocabulary The words you use demonstrate your mastery of writing, and how well you can make an argument. A university-level essay should display a similar level of vocabulary. Make certain you are using words correctly. Synonyms can have different shades of meaning; the wrong one could sully your message. Find examples of how words are used before using them. Use plain language most of the time. Overusing big words can make your writing seem pretentious. Think of advanced words as a spice, and your ideas as the main dish. Write distinct essays Every university has a distinct culture. An admission essay is a statement that you are a good fit for that particular school. If you’re applying for more than one place, write a distinct essay for each. Some of your points may not apply to every university. Research and learn about their individual cultures, values, and awards. Tailor your work to make it relevant to each unique mission and values. Be concise Applying to university is much like applying for a job. You are given only so much space to show why you deserve a spot. Meet their specifications, but be brief. Admissions officers have to read several essays each day. You have a few hundred words to grab their attention. Be precise, organize your thoughts, and show that you’re respectful of others’ time. Edit The job isn’t done when you have finished writing. Proofreading and editing your essay is an essential step, and can play a major role in separating your work from the crowd. Check the word count and make sure it complies with requirements. Read each sentence to ensure that your thoughts are expressed clearly. Check for spelling, punctuation, and grammatical errors. A thorough read-through will help spot errors, and result in a better submission. Seek a second opinion Before submitting the essay, ask for advice from someone qualified. Sometimes others can spot mistakes a writer might miss. If you can, ask someone with expertise in the admissions process. Ask a teacher you trust to give feedback. Ask only a few select people for help; too much feedback can affect the quality of your writing. Remember, the essay should present your thoughts the way you want them heard. One of the most important things you can do is to start writing early. Give yourself plenty of time to write and finish well ahead of the deadline. Use extra time to fine-tune the essay and make it the best it can be. In case of any setbacks, you have time to edit and rewrite your work. Good writing skills can help in any facet of life, and they are essential for success at university. A good admissions essay is only the first step. Once you are in school, you’ll need those skills to write quality research papers and other projects. Sometimes, a university workload can be difficult to handle. In that case, give a call for help with writing papers and presentations. specializes in quality academic writing. For quality research, an organized layout, and logical reasoning, get our writing team on your side.

Give a topic Research Paper Example | Topics and Well Written Essays - 500 words

Give a topic - Research Paper Example This was mainly driven by the steadily growing population which gave rise to a growth in agriculture, trade and industry (Fairbank & Merle 89). China’s economy in this period was based on agriculture and all other sectors were either drawing from it or servicing it. In the era of the Song dynasty, China’s agricultural system was the most productive worldwide. However, China’s fast raising population quickly led to a decline in labor costs towards the 19th century (Fairbank & Merle 93). To overcome the situation, industrial producers started substituting labor for capital goods whenever the chance presented itself. Similarly, Japan’s population grew in the same period. A national unifier named Tokugawa Ieyasu established a dynasty after victory in battle. This gave way to changes including bringing in new crops from the West and Chinese technology in civil works. More land was put under irrigation. The government, under Tokugawa, opened up trade with the We stern world and encouraged its people to take part in economic activities. It promoted industrialization by helping private businesses in allocation of resources and planning, while the private sector stimulated economic growth (Mosk 41). But unlike China, Japan’s growing population did not bring about a decline in labor costs. In the 19th century, China and Japan were faced with similar situations of advancing industrialization with moderately low productivity levels in agriculture. Low agricultural productivity translated into low wages, and this factor presented both a challenge and an advantage (Fairbank & Merle 104). It meant that the labor supply in agriculture was elastic enough to move to manufacturing, which was an advantage. However, the challenge was how the farm labor could be freed up for employment in the factories by raising productivity of labor in farming. The different decisions made by the two countries to raise productivity of

Domestic Terrorism Essay Example | Topics and Well Written Essays - 250 words

Domestic Terrorism - Essay Example For instance, the Southern Poverty Law Center (SPLC) reported that as of 2010, there were more than 1000 hate groups in America (Bjelopera, 2013). Furthermore, political polarization in the US has been intense in recent years, and there has been a widespread distrust in the government. These are some of the factors further contributing to the growth of domestic terrorists in the US. Although domestic terrorism is a threat, international terrorism is more dangerous to the general American public. This is because most of the domestic terrorists use non-violent approaches that do not directly cause harm to the American public. For instance, animal rights extremists use what they call ‘direct action’ which mainly involves protests and other resistance activities. In addition, non-violent criminal activities involving fraud and cyber-terrorism are also used by domestic terrorists, and these do not necessarily cause direct harm to the public (Bjelopera, 2013). However, for international terrorists, their main aim is usually to kill and cause maximum damage. For example, the 911 attack left more than 3000 dead and property worth billions of dollars destroyed. No domestic terrorist activity can ever get close to

Acute Exacerbation of Bronchial Asthma (AEBA) Case Study

Acute Exacerbation of Bronchial Asthma (AEBA) Case Study 1.0 CASE SUMMARY 1.1 Patient information and presenting complaints SAR, a 54-year-old female with weight of 54kg and height of 160cm was referred to the hospital by her GP due to shortness of breath which was not relieved by taking inhaler, minimum cough with yellowish sputum, abdominal pain and mild diarrhoea. Her shortness of breath had been on and off for the past 1 week and the condition was deteriorating on the day of admission. 1.2 Relevant history SAR is a non-smoker and a non-alcoholic housewife. She has had bronchial asthma since childhood. Her siblings and children were found to have family history of bronchial asthma as well. The patient has been taking inhaled salbutamol 200 µg 1 puff when required as reliever and inhaled budesonide 200 µg 2puffs bd as preventer for umpteen years. Besides that, SAR also has medical history of hypertension, diabetes mellitus and ischaemic heart disease (IHD) for 10 years. She has no relevant family history for these illnesses. For the past few years, SAR has been taking rosuvastatin 20mg at night, fenofibrate 160mg OD and ezetimibe 10mg OD for dyslipidaemia, gliclazide 60mg BD and rosiglitazone 4mg OD for diabetes mellitus, losartan 50mg OD for hypertension, ticlopidine hydrochloride 250mg OD for prophylaxis against major ischaemic events and famotidine 20mg OD to prevent gastrointestinal ulceration due to the use of anti-platelet agent. 1.3 Clinical data On examination upon admission, SARs blood pressure and pulse rate were recorded as 111/80 mmHg and 111bpm respectively. Her respiratory rate was normal (16 breaths/min). Her SpO2 measurement was 98% and it showed decreased high flow mask. Her DXT blood glucose test revealed that her random blood glucose level was abnormally high (21.6mmol/L). From the doctors systemic enquiry, SARs ankles were slightly swollen and her respiratory system showed prolonged minimal bibasal crept and rhonchi. Also, SARs chest X-ray showed shadowing in the lower zone of her right lung. The renal function tests gave results of high urea and elevated creatinine levels of 16.3mmol/L and 270 µmol/L respectively. Creatinine clearance derived from Cockcroft and Gault formula is 17ml/min which indicates that the patient has severe renal impairment. The liver function tests revealed a mild decrease in albumin concentration and an increase in the plasma globulin. On the other hand, the haematological tests showed low red blood cell count (3.41012/L), low haemoglobin count (9.4g/dL), high platelet count (410109/L), high white blood cell count (17.1109/L), high neutrophil count (16.4109/L) and low lymphocyte count (0.5109/L), whereas cardiac marker tests showed abnormally high counts in creatine kinase (156IU/L) and lactate dehydrogenase (627IU/L). 1.4 Diagnosis and Management Plan Based on the patients symptoms, medical history, physical examinations, and laboratory tests, SAR was diagnosed with chronic heart failure (CHF), acute exacerbation of bronchial asthma (AEBA) secondary to pneumonia and uncontrolled diabetes mellitus. Her doctor developed therapeutic plans which included anti-asthmatic drugs and antibiotics, and ordered further investigations such as SpO2 and PEFR. Besides that, her doctor also added diuretic to her ACEI therapy and restrict her fluid intake to not more than 800cc/day. Her uncontrolled diabetes mellitus was under monitoring of DXT blood glucose test 4 hourly and she was referred to dietician for diabetic diet counselling. 1.5 Ward medication Throughout the 3days in hospital, Sarah was being prescribed with medications as listed below: 1.6 Clinical Progress and Pharmaceutical Care Issues On the first day of admission, the patients past medication history was confirmed by appropriate patient interview and her family members were being advised to bring SARs home medication to ensure that the appropriate medications were continued and prescribed. From the interview, dust was found to be the chief precipitating factor. The patient was on appropriate drugs (nebulised ipratropium bromide 0.5mg and nebulised salbutamol 5mg in normal saline 4 hourly, IV hydrocortisone 100mg stat) for acute management of severe asthma as according to guidelines and eventually her SOB was relieved.2-3 However, she was prescribed with oral prednisolone at dose as low as 30mg od for acute asthma, it should be suggested to increase prednisolone dose to 40-50mg daily as according to evidence-based guidelines to achieve maximal effects.2-3 Another pharmaceutical care issue is regarding the patients poor inhaler technique. Thus, the pharmacist educated and assessed SAR on her inhaler technique since day 1. Appropriate antibiotics indicated for pneumonia which included IV ceftriaxone 2g stat and oral azitromycin 500mg od were initiated upon admission. Oral cefuroxime 250mg bd was added to the drug regimen on day 2 after stopping IV ceftriaxone 2g on the first day. Therefore, signs of recovery and WBC count were monitored regularly and completion of antibiotic course was ensured. In addition to that, vaccinations against pneumococcal infection and influenza should be strongly recommended in this asthmatic patient.2-3,5-8 Co-administration of high dose IV furosemide (40mg bd) and corticosteroids can increase the risk of hypokalaemia, therefore SAR should be started on potassium chloride 600mg bd which is an appropriate dose for renal insufficiency patient to avoid the potential risk.1 Besides that, potassium level of SAR should also be closely monitored during the administration of potassium chloride. The doctor added lovastatin 20mg at night to her existing triple therapy of dyslipidaemia (rosuvastatin, ezetimibe, fenofibrate). Rosuvastatin should be avoided if patients creatinine clearance is less than 30ml/min.1 Due to its same mechanism of action as lovastatin and its contraindication in patient with severe renal impairment, rosuvastatin should be withdrawn from the drug regimen. Practically, a comprehensive lipid profile of SAR should be established and monitored in order to choose the best combination of lipid lowering agents to improve the individual components of lipid profile. Combination therapy of ezetimibe and lovastatin is considered more appropriate as concurrent use of fenofibrate and statin may potentiate myopathy. Therefore, fenofibrate and rosuvastatin should not be continued. Liver function should be monitored to avoid the risk of hepatotoxicity. SAR was diagnosed with uncontrolled diabetes mellitus which means her blood glucose level was not adequately controlled with concurrent therapy of gliclazide and rosiglitazone. Her random blood glucose level was fluctuating throughout day 1 (24.9mmol/L, 14.2mmol/L, 7.3mmol/L and 14.7mmol/L). Targets for blood glucose levels should be ideally maintained between 4 and 7mmol/L pre-meal and On day 2, SAR was feeling much more comfortable and had not complaint of SOB. However, SARs maintenance management of asthma was found to be not conformed to the asthma guidelines.2-3 She was prescribed with unacceptable high dose of corticosteroids (MDI beclomethasone 200 µg 2 puffs tds) in addition to her current steroid regimen (MDI budesonide 200 µg 2 puffs bd and oral prednisolone 30mg od). SAR was at potential high risk of experiencing considerable side effects such as diabetes, oesteoporosis, Cushing syndrome with moon face, striae, acne, abdominal distension and other profound effects on musculoskeletal, neuropsychiatric and ophthalmic systems as a result of overdosage of corticosteroids.1 Oropharyngeal side effects such as candidiasis are also more common at high dose of inhaled steroids, but can be minimized if the patient rinse the mouth with water after inhalation. It should be recommended to add the long acting beta agonist (LABA) to the inhaled corticosteroids (ICS) treatment instead of initiating SAR on high dose steroid (2000 µg). Combination inhaler of formoterol and budesonide (Symbicort 200/6 Turbohaler ® 2 puffs bd) should be given and control of asthma need to be continuing assessed.2-3 If LABA is proved to be not effective, addition of 4th agent (leukotriene receptor antagonist, theophylline or oral beta agonist) can be considered.2 When SAR showed recovery of leg swelling, furosemide was given orally instead of intravenously with reduced frequency and total daily dose. On day 3, SAR was arranged to be discharged. The pharmacist should review the appropriateness of discharged medication by checking discharged prescriptions against ward medication chart and ensure all information relevant to primary care referrals are included. In addition to that, the pharmacist should also reiterate and reinforce the importance of patient compliance and follow-up reviews, counsel on indications, doses and possible adverse effects of each discharged medication, and rechecked SARs inhaler and insulin injection techniques prior discharged. Asthma education includes advice to avoid trigger factors, including caution with NSAIDs and avoidance of dust exposure. Greater attention should be paid to inhaler technique as poor technique leading to failure of treatment. SAR should be educated on the use of peak flow meters and advised to monitor and record her own PEFR at home. A written personalised asthma action plans should be designed for SAR prior discharged. Diabetic cou nselling should emphasize on proper insulin injection techniques and healthy lifestyle modifications. SAR needs to be made aware of the signs of hypoglycaemia and hyperglycaemia and how to response to them. Polypharmacy may adversely affect compliance with prescribed drug therapy, therefore SAR should be taught not to mix up her medicines by using daily pill box and her family member should also be advised to supervise her on medicine taking. 2.0 PHARMACOLOGICAL BASIS OF DRUG THERAPY 2.1 Disease background 2.1.1 Asthma Asthma is a common chronic inflammatory condition of the lung airways affecting 5-10% of the population and appears to be on the increase.5 It is especially prevalent in children, but also has a high incidence in more elderly patient. Asthma mortality is approximately 1500 per annum in the UK and costs in the region of  £2000 million per year in health and other costs.2-3,6 Symptoms of asthma are recurrent episodes of dyspnoea, chest tightness, cough and wheeze (particularly at night or early in the morning) caused by reversible airway obstruction. Three factors contribute to airway narrowing: bronchoconstriction triggered by airway hyperresponsiveness to a wide range of stimuli; mucosal swelling/inflammation caused by mast cell, activated T lymphocytes, macrophages, eosinophils degranulation resulting in the release of inflammatory mediators; smooth muscle hypertrophy, excessive mucus production and airway plugging.7 There is no single satisfactory diagnostic test for all asthmati c patients. The useful tests for airway function abnormalities include the force expiratory volume (FEV1), force vital capacity (FVC) and peak expiratory flow rate (PEFR). The diagnosis is based on demonstration of a greater than 15% improvement in FEV1 or PEFR following the inhalation of a bronchodilator.2,3,6 Repeated pre and post-bronchodilator readings taken at various times of the day is necessary. The FEV1 is usually expressed as the percentage of total volume of air exhaled and is reported as the FEV1/FVC ratio. The ratio is a useful and highly reproducible measure of lungs capabilities. Normal individuals can exhale at least 75% of their total capacity in 1 second. A decrease in FEV1/FVC indicates airway obstruction. 2.1.2 Community-acquired pneumonia Pneumonia is defined as inflammation of the alveoli as opposed to the bronchi and of infective origin. It presents as an acute illness clinically characterized by the presence of cough, purulent sputum, breathlessness, fever and pleuritic chest pains together with physical signs or radiological changes compatible with consolidation of the lung, a pathological process in which the alveoli are filled with bacteria, white blood cells and inflammatory exudates. The incidence of community acquired pneumonia (CAP) reported annum in UK is 5-11 per 1000 adult population, with mortality rate varies between 5.7% and 14% (patients hospitalised with CAP).8 Streptococcus pneumonia is the commonest cause, followed by Haemophilus influenzae and Mycoplasma penumoniae.7 2.1.3 Congestive cardiac failure Congestive cardiac failure occurs when the heart fails to pump an adequate cardiac output to meet the metabolic demands of the body. It is a common condition with poor prognosis (82% of patients dying within 6 years of diagnosis) and affects quality of life in the form of breathlessness, fatigue and oedema.6,7 The common underlying causes of cardiac failure are coronary artery disease and hypertension. Defects in left ventricular filling and/or emptying causes inadequate perfusion, venous congestion and disturbed water and electrolyte balance. In chronic cardiac failure, the maladaptive body compensatory mechanism secondary physiological effects contribute to the progressive nature of the disease.6 2.1.4 Diabetes mellitus Diabetes mellitus is a heterogenous group of disorders characterised by chronic hyperglycaemia due to relative insulin deficiency and/or resistance. It can be classified as either Type 1 or Type 2. In Type 1, there is an inability to produce insulin and is generally associated with early age onset. Decreased insulin production and/or reduced insulin sensitivity, maturity onset and strong correlation with obesity are characteristics of Type 2 diabetes. Diabetes affects 1.4 million people in the UK, over 75% of them have Type 2 diabetes.6 It is usually irreversible and if not adequately managed, its late complications can result in reduced life expectancy and considerable uptake of health resources. 2.2 Drug pharmacology 2.2.1 Treatment for asthma 2.2.1.1Beta-adrenoceptor agonists (e.g. salbutamol, terbutaline) These short-acting selective ÃŽ ²2 agonists (SABA) are the first line agents in the management of asthma and are also known as relievers. The selective ÃŽ ²2 agonists act on ÃŽ ²2 aderenoceptors on the bronchial smooth muscle to increase cyclic adenosine monophosphate (cAMP) leading to rapid bronchodilation and reversal of the bronchospasm associated with the early phase of asthmatic attack.5 Such treatment is very effective in relieving symptoms but does little for the underlying inflammatory nature of the disease. ÃŽ ²2 agonists should be initiated ‘when required as prolonged use may lead to receptor down regulation renders them less effective.5-6 Compared to SABA, long-acting beta-adrenoceptor agonists (e.g. salmeterol, formoterol) have slower rate of onset and their intrinsic lipophilic properties render them to be retained near the receptor for a prolonged period (12hours), which means that they cause prolonged bronchodilation. 2.2.1.2 Muscarinic receptor antagonists (e.g. ipratropium) Ipratropium blocks parasympathetic-mediated bronchoconstriction by competitively inhibiting muscarinic M3 receptors in bronchial smooth muscle.1,5-6 It has slower onset of action than ÃŽ ²2 agonists but last longer. 2.2.1.3 Inhaled corticosteroids (ICS; e.g. beclomethasone, budesonide) and oral prednisolone These agents are used to prevent asthmatic attacks by reducing airway inflmmation. They exert their anti-inflammatory actions via activation of intracellular receptors, leading to altered gene transcription. This results in decreased cytokine production and the synthesis of lipocortin leading to phospholipase A2 inhibition, and the inhibition of leukotriene and prostaglandins.5 Candidiasis occurs as common side effects with inhalation and systemic steroid effects such as adrenal suppression and osteoporosis, occur with high dose inhalation or oral dosing. 2.2.2 Treatment for pneumonia Antiobiotic treatment is appropriate with amoxicillin being used as first choice agent for mild, community-acquired infections. Depending on response and the strain of bacteria, other antibiotic agents can be used. Two groups of antibiotics which were given to the patient in this case scenario will be discussed here. 2.2.2.1 Cephalosporins (e.g. cefuroxime, ceftriaxone) Both ceftriaxone and cefuroxime are broad spectrum bactericidal antibiotics belong to cephalosporins group. They inhibit the synthesis of bacterial cell wall by binding to specific penicillin-binding proteins and ultimately leading to cell lysis. Second generation cefuroxime is beta-lactamase resistant and active against Gram-negative bacteria such as Haemophilus influenzae and Klebsiella pneumoniae. Being third generation cephalosporin, ceftriaxone display high beta–lactamase resistance and enhanced activity against Gram-negative pathogens (including Pseudomonas Aeruginosa), but it has relatively poor activity against Gram-positive organisms and anaerobes.1,5-6 2.2.2.2 Maclolides (e.g. azithromycin, erythromycin, clarithromycin) Maclolides prevent protein synthesis by inhibiting the translocation movement of the bacterial ribosome along the mRNA, resulting in bacteriostatic actions. Azithromycin has slightly less activity than erythromycin against Gram-positive organisms but possesses enhanced activity against Gram-negative bacteria including Haemophilus influenza. 2.2.3 Treatment for chronic cardiac failure 2.2.3.1 Loop diuretics (e.g. furosemide) Diuretics are the mainstay of the management of heart failure and provide rapid symptomatic relief of pulmonary and peripheral oedemia.5,6,9 Loop diuretics are indicated in majority of symptomatic patients and they work by inhibiting Na+/K+/2Cl- transporter in the ascending limb of the loop of Henle, inhibiting the establishment of a hyperosmotic interstitium and thus reducing the production of concentrated urine in kidney, leading to profuse dieresis.5-6 2.2.3.2 Angiotensin II receptor antagonists (e.g. losartan, candesartan, valsartan) These agents block the action of angiotensin II at the AT1 receptor, which will also reduce the stimulation of aldosterone release. Therefore AT1 receptor antagonists can be used as an alternative in patients suffering from a cough secondary to ACE inhibitors. 2.2.4 Treatment for Type II diabetes mellitus 2.2.4.1 Sulphonylureas (e.g. Gliclazide, glibenclamide, glipizide) The sulphonylureas have two main actions: increase basal and stimulated insulin secretion and reduce peripheral resistance to insulin action. They bind to receptors associated with voltage dependent KATP channels on the surface of pancreatic beta cell, causing channel closure which facilitates calcium entry into the cell and leads to insulin release. Sulphonylureas are considered in Type II diabetes patients who are intolerant to metformin, not contraindicated and not overweight. 2.2.4.2 Thiazolidinediones (e.g. rosiglitazone, pioglitazone) These new agents are ‘insulin sensitisers which act as nuclear peroxisome proliferator-activated receptor-gamma (PPAR-ÃŽ ³) agonist. They work by enhancing insulin action and promoting glucose utilization in peripheral tissue, and so reduce insulin resistance. Thiazolidinediones is known to be associated with oedema and increased cardiovascular risks, therefore these agents should be avoided in patients with heart failure.1,4,6 3.0 EVIDENCE FORTREATMENT OF CONDITIONS 3.1 Asthma 3.1.1 Evidence for the use of oral prednisolone and IV hydrocortisone in the management of AEBA There are mounting evidences suggesting that systemic corticosteroids effectively influence the airway oedema and mucus plugging associated with acute asthma by suppressing the components of inflammation, including the release of adhesion molecules, airway permeability and production of cytokines.10-12 A randomised trial involving 88 patients (aged 15-70years) with AEBA reported the significant efficacy of oral prednisolone (40mg daily for 7 days) in improving FEV1 and FVC at values of 68 ±45.3% and 53.4 ±46.5% respectively (P=0.04) in prednisolone-treated group.13 A Cochrane meta-analysis involving six trials recruiting 374 acute asthmatic exacerbation patients determined the early use of systemic corticosteroids significantly reduced the number of relapses to additional care, hospitalisation and use of short-acting ÃŽ ²2-agonist without increasing side effects, regardless of the routes of administration studied (oral/intramuscular/intravenous) and choice of agents.14 3.1.2 Evidence for the use of inhaled ipratropium bromide in the management of AEBA A double-blind, randomised controlled trials recruiting 180 patients with AEBA admitted to emergency department showed that ipratropium had beneficial effects in improving pulmonary function, with a 20.5% increment in PEF (p=0.02) and a 48.1% greater improvements in FEV1 (p=0.0001) compared to those given ÃŽ ²2-agonists alone. Ipratropium also demonstrated a 49% reduction in the risk of hospital admission.15 A more recent meta-analysis incorporating thirty-two double-blind, randomised controlled trials including 3611 patients with moderate to severe exacerbations of asthma also showed the benefits of combination treatment of nebuliser ÃŽ ²2-agonists and anti-muscarinic in reducing hospital admissions (relative risk 0.68,p=0.002) and in producing a significant increase in lung function parameters in AEBA patients (standard mean difference -0.36, p=0.00001).16 Another pooled analysis of three multicenter, double-blind, randomised controlled studies also showed that combination therapy of ipratropium bromide and salbutamol for the treatment of AEBA had decreased risk of the need for additional treatment (relative risk=0.92), asthma exacerbation (relative risk=0.84) and hospitalisation (relative risk=0.80).17 3.1.3 Evidence for addition of LABA to ICS in the management of asthma Symbicort Maintenance and Reliever Therapy (SMART) studies demonstrated the combined use of formoterol/budesonide contributes to a greater reduction in risks of exacerbations, improved lungs performance and better control of asthma than high dose of ICS with SABA.18-22 These studies also reported the advantage of this approach in terms of patient compliance as it allows the use of single inhaler for both rescue and controller therapy, and reductions in healthcare costs.18-22 A large double-blind, randomised trial reported that there was a significant 21-39% reduction of severe exacerbations in asthmatic patients treated with SMART therapy compared with high dose budesonide plus SABA.23 A meta-analysis involving 30 trials with 9509 patients showed that the use of combination inhaler (formoterol/beclomethasone 400mcg) resulted in greater improvement in FEV1, in the use of rescue SABA and in the symptom-free days compared to a higher dose of ICS (800-1000mcg/day).24 Another double-blind randomised trial investigating the effect of combination budesonide and formoterol as reliever therapy for 3394 patients who were assigned budesonide plus formoterol for maintenance therapy showed that the time to first severe exacerbation was significantly longer in as needed budesonide/formoterol group compared to as needed terbutaline group (p=0.0051). The other finding of the study is the significant lower rate of severe exacerbation for as needed budesonide/formoterol versus as needed terbutaline group (0.19 vs 0.37, p 3.2 Community-acquired pneumonia 3.2.1 Evidence use of combination therapy of second and/or third generation cephalosporins and macrolide in the management of pneumonia A multicenter, randomised trial investigated the efficacy of IV ceftriaxone 2g for 1 day followed by oral cefuroxime 500mg bd in the adult pneumonia treatment. The sequential therapy in combination with a macrolide achieved 90% of clinical success, 85% of overall bacteriologic clearance with 100% eradication of S.pneumoniae after 5-7days of treatment.27 An open label, prospective study involving 603 patients demonstrated that adding azithromycin (500mg od for 3days) to IV ceftriaxone 1g/day in the treatment of community-acquired pneumonia resulted in shorter hospital stay (7.3days vs 9.4days) and a significant lower mortality rate (3.7% vs 7.3%) than adding clarithromycin.28 Lack of randomisation and no blinding of evaluators may become the major limitations of this study; however the effectiveness of macrolide in addition to cephalosporins empirical therapy in treating pneumonia is unquestionable. 3.3 Chronic heart failure 3.3.1 Evidence use of loop diuretic in the management of chronic heart failure (CHF) A meta-analysis of 18 randomised controlled trials concluded that diuretics significantly lowered the mortality rate (odds ratio (OR) 0.25, P=0.03) and reduced hospital admissions for worsening heart failure (OR 0.31, P=0.001) in patients with CHF compared to placebo.29 Compared to active control, diuretics significantly improved exercise capacity in CHF patients. (OR 0.37, P=0.007).29 A recent review reappraisaled the role of loop diuretics as first line treatment for CHF concluded that existing evidence of association of loop diuretics with rapid symptomatic relief and decreased mortality supporting the essential role of diuretics in the management of CHF.30 3.3.2 Evidence use of angiotensin II receptor antagonists in the management of CHF The Losartan Heart Failure Survival Study ELITE II, a double-blind, randomised controlled trial involved 3152 patients with NYHA class II-IV heart failure and ejection fraction ≠¤40% reported that there were no significant differences between losartan and enalapril groups in all cause mortality (11.7 vs 10.4% mean mortality rate). However, losartan Acute Exacerbation of Bronchial Asthma (AEBA) Case Study Acute Exacerbation of Bronchial Asthma (AEBA) Case Study 1.0 CASE SUMMARY 1.1 Patient information and presenting complaints SAR, a 54-year-old female with weight of 54kg and height of 160cm was referred to the hospital by her GP due to shortness of breath which was not relieved by taking inhaler, minimum cough with yellowish sputum, abdominal pain and mild diarrhoea. Her shortness of breath had been on and off for the past 1 week and the condition was deteriorating on the day of admission. 1.2 Relevant history SAR is a non-smoker and a non-alcoholic housewife. She has had bronchial asthma since childhood. Her siblings and children were found to have family history of bronchial asthma as well. The patient has been taking inhaled salbutamol 200 µg 1 puff when required as reliever and inhaled budesonide 200 µg 2puffs bd as preventer for umpteen years. Besides that, SAR also has medical history of hypertension, diabetes mellitus and ischaemic heart disease (IHD) for 10 years. She has no relevant family history for these illnesses. For the past few years, SAR has been taking rosuvastatin 20mg at night, fenofibrate 160mg OD and ezetimibe 10mg OD for dyslipidaemia, gliclazide 60mg BD and rosiglitazone 4mg OD for diabetes mellitus, losartan 50mg OD for hypertension, ticlopidine hydrochloride 250mg OD for prophylaxis against major ischaemic events and famotidine 20mg OD to prevent gastrointestinal ulceration due to the use of anti-platelet agent. 1.3 Clinical data On examination upon admission, SARs blood pressure and pulse rate were recorded as 111/80 mmHg and 111bpm respectively. Her respiratory rate was normal (16 breaths/min). Her SpO2 measurement was 98% and it showed decreased high flow mask. Her DXT blood glucose test revealed that her random blood glucose level was abnormally high (21.6mmol/L). From the doctors systemic enquiry, SARs ankles were slightly swollen and her respiratory system showed prolonged minimal bibasal crept and rhonchi. Also, SARs chest X-ray showed shadowing in the lower zone of her right lung. The renal function tests gave results of high urea and elevated creatinine levels of 16.3mmol/L and 270 µmol/L respectively. Creatinine clearance derived from Cockcroft and Gault formula is 17ml/min which indicates that the patient has severe renal impairment. The liver function tests revealed a mild decrease in albumin concentration and an increase in the plasma globulin. On the other hand, the haematological tests showed low red blood cell count (3.41012/L), low haemoglobin count (9.4g/dL), high platelet count (410109/L), high white blood cell count (17.1109/L), high neutrophil count (16.4109/L) and low lymphocyte count (0.5109/L), whereas cardiac marker tests showed abnormally high counts in creatine kinase (156IU/L) and lactate dehydrogenase (627IU/L). 1.4 Diagnosis and Management Plan Based on the patients symptoms, medical history, physical examinations, and laboratory tests, SAR was diagnosed with chronic heart failure (CHF), acute exacerbation of bronchial asthma (AEBA) secondary to pneumonia and uncontrolled diabetes mellitus. Her doctor developed therapeutic plans which included anti-asthmatic drugs and antibiotics, and ordered further investigations such as SpO2 and PEFR. Besides that, her doctor also added diuretic to her ACEI therapy and restrict her fluid intake to not more than 800cc/day. Her uncontrolled diabetes mellitus was under monitoring of DXT blood glucose test 4 hourly and she was referred to dietician for diabetic diet counselling. 1.5 Ward medication Throughout the 3days in hospital, Sarah was being prescribed with medications as listed below: 1.6 Clinical Progress and Pharmaceutical Care Issues On the first day of admission, the patients past medication history was confirmed by appropriate patient interview and her family members were being advised to bring SARs home medication to ensure that the appropriate medications were continued and prescribed. From the interview, dust was found to be the chief precipitating factor. The patient was on appropriate drugs (nebulised ipratropium bromide 0.5mg and nebulised salbutamol 5mg in normal saline 4 hourly, IV hydrocortisone 100mg stat) for acute management of severe asthma as according to guidelines and eventually her SOB was relieved.2-3 However, she was prescribed with oral prednisolone at dose as low as 30mg od for acute asthma, it should be suggested to increase prednisolone dose to 40-50mg daily as according to evidence-based guidelines to achieve maximal effects.2-3 Another pharmaceutical care issue is regarding the patients poor inhaler technique. Thus, the pharmacist educated and assessed SAR on her inhaler technique since day 1. Appropriate antibiotics indicated for pneumonia which included IV ceftriaxone 2g stat and oral azitromycin 500mg od were initiated upon admission. Oral cefuroxime 250mg bd was added to the drug regimen on day 2 after stopping IV ceftriaxone 2g on the first day. Therefore, signs of recovery and WBC count were monitored regularly and completion of antibiotic course was ensured. In addition to that, vaccinations against pneumococcal infection and influenza should be strongly recommended in this asthmatic patient.2-3,5-8 Co-administration of high dose IV furosemide (40mg bd) and corticosteroids can increase the risk of hypokalaemia, therefore SAR should be started on potassium chloride 600mg bd which is an appropriate dose for renal insufficiency patient to avoid the potential risk.1 Besides that, potassium level of SAR should also be closely monitored during the administration of potassium chloride. The doctor added lovastatin 20mg at night to her existing triple therapy of dyslipidaemia (rosuvastatin, ezetimibe, fenofibrate). Rosuvastatin should be avoided if patients creatinine clearance is less than 30ml/min.1 Due to its same mechanism of action as lovastatin and its contraindication in patient with severe renal impairment, rosuvastatin should be withdrawn from the drug regimen. Practically, a comprehensive lipid profile of SAR should be established and monitored in order to choose the best combination of lipid lowering agents to improve the individual components of lipid profile. Combination therapy of ezetimibe and lovastatin is considered more appropriate as concurrent use of fenofibrate and statin may potentiate myopathy. Therefore, fenofibrate and rosuvastatin should not be continued. Liver function should be monitored to avoid the risk of hepatotoxicity. SAR was diagnosed with uncontrolled diabetes mellitus which means her blood glucose level was not adequately controlled with concurrent therapy of gliclazide and rosiglitazone. Her random blood glucose level was fluctuating throughout day 1 (24.9mmol/L, 14.2mmol/L, 7.3mmol/L and 14.7mmol/L). Targets for blood glucose levels should be ideally maintained between 4 and 7mmol/L pre-meal and On day 2, SAR was feeling much more comfortable and had not complaint of SOB. However, SARs maintenance management of asthma was found to be not conformed to the asthma guidelines.2-3 She was prescribed with unacceptable high dose of corticosteroids (MDI beclomethasone 200 µg 2 puffs tds) in addition to her current steroid regimen (MDI budesonide 200 µg 2 puffs bd and oral prednisolone 30mg od). SAR was at potential high risk of experiencing considerable side effects such as diabetes, oesteoporosis, Cushing syndrome with moon face, striae, acne, abdominal distension and other profound effects on musculoskeletal, neuropsychiatric and ophthalmic systems as a result of overdosage of corticosteroids.1 Oropharyngeal side effects such as candidiasis are also more common at high dose of inhaled steroids, but can be minimized if the patient rinse the mouth with water after inhalation. It should be recommended to add the long acting beta agonist (LABA) to the inhaled corticosteroids (ICS) treatment instead of initiating SAR on high dose steroid (2000 µg). Combination inhaler of formoterol and budesonide (Symbicort 200/6 Turbohaler ® 2 puffs bd) should be given and control of asthma need to be continuing assessed.2-3 If LABA is proved to be not effective, addition of 4th agent (leukotriene receptor antagonist, theophylline or oral beta agonist) can be considered.2 When SAR showed recovery of leg swelling, furosemide was given orally instead of intravenously with reduced frequency and total daily dose. On day 3, SAR was arranged to be discharged. The pharmacist should review the appropriateness of discharged medication by checking discharged prescriptions against ward medication chart and ensure all information relevant to primary care referrals are included. In addition to that, the pharmacist should also reiterate and reinforce the importance of patient compliance and follow-up reviews, counsel on indications, doses and possible adverse effects of each discharged medication, and rechecked SARs inhaler and insulin injection techniques prior discharged. Asthma education includes advice to avoid trigger factors, including caution with NSAIDs and avoidance of dust exposure. Greater attention should be paid to inhaler technique as poor technique leading to failure of treatment. SAR should be educated on the use of peak flow meters and advised to monitor and record her own PEFR at home. A written personalised asthma action plans should be designed for SAR prior discharged. Diabetic cou nselling should emphasize on proper insulin injection techniques and healthy lifestyle modifications. SAR needs to be made aware of the signs of hypoglycaemia and hyperglycaemia and how to response to them. Polypharmacy may adversely affect compliance with prescribed drug therapy, therefore SAR should be taught not to mix up her medicines by using daily pill box and her family member should also be advised to supervise her on medicine taking. 2.0 PHARMACOLOGICAL BASIS OF DRUG THERAPY 2.1 Disease background 2.1.1 Asthma Asthma is a common chronic inflammatory condition of the lung airways affecting 5-10% of the population and appears to be on the increase.5 It is especially prevalent in children, but also has a high incidence in more elderly patient. Asthma mortality is approximately 1500 per annum in the UK and costs in the region of  £2000 million per year in health and other costs.2-3,6 Symptoms of asthma are recurrent episodes of dyspnoea, chest tightness, cough and wheeze (particularly at night or early in the morning) caused by reversible airway obstruction. Three factors contribute to airway narrowing: bronchoconstriction triggered by airway hyperresponsiveness to a wide range of stimuli; mucosal swelling/inflammation caused by mast cell, activated T lymphocytes, macrophages, eosinophils degranulation resulting in the release of inflammatory mediators; smooth muscle hypertrophy, excessive mucus production and airway plugging.7 There is no single satisfactory diagnostic test for all asthmati c patients. The useful tests for airway function abnormalities include the force expiratory volume (FEV1), force vital capacity (FVC) and peak expiratory flow rate (PEFR). The diagnosis is based on demonstration of a greater than 15% improvement in FEV1 or PEFR following the inhalation of a bronchodilator.2,3,6 Repeated pre and post-bronchodilator readings taken at various times of the day is necessary. The FEV1 is usually expressed as the percentage of total volume of air exhaled and is reported as the FEV1/FVC ratio. The ratio is a useful and highly reproducible measure of lungs capabilities. Normal individuals can exhale at least 75% of their total capacity in 1 second. A decrease in FEV1/FVC indicates airway obstruction. 2.1.2 Community-acquired pneumonia Pneumonia is defined as inflammation of the alveoli as opposed to the bronchi and of infective origin. It presents as an acute illness clinically characterized by the presence of cough, purulent sputum, breathlessness, fever and pleuritic chest pains together with physical signs or radiological changes compatible with consolidation of the lung, a pathological process in which the alveoli are filled with bacteria, white blood cells and inflammatory exudates. The incidence of community acquired pneumonia (CAP) reported annum in UK is 5-11 per 1000 adult population, with mortality rate varies between 5.7% and 14% (patients hospitalised with CAP).8 Streptococcus pneumonia is the commonest cause, followed by Haemophilus influenzae and Mycoplasma penumoniae.7 2.1.3 Congestive cardiac failure Congestive cardiac failure occurs when the heart fails to pump an adequate cardiac output to meet the metabolic demands of the body. It is a common condition with poor prognosis (82% of patients dying within 6 years of diagnosis) and affects quality of life in the form of breathlessness, fatigue and oedema.6,7 The common underlying causes of cardiac failure are coronary artery disease and hypertension. Defects in left ventricular filling and/or emptying causes inadequate perfusion, venous congestion and disturbed water and electrolyte balance. In chronic cardiac failure, the maladaptive body compensatory mechanism secondary physiological effects contribute to the progressive nature of the disease.6 2.1.4 Diabetes mellitus Diabetes mellitus is a heterogenous group of disorders characterised by chronic hyperglycaemia due to relative insulin deficiency and/or resistance. It can be classified as either Type 1 or Type 2. In Type 1, there is an inability to produce insulin and is generally associated with early age onset. Decreased insulin production and/or reduced insulin sensitivity, maturity onset and strong correlation with obesity are characteristics of Type 2 diabetes. Diabetes affects 1.4 million people in the UK, over 75% of them have Type 2 diabetes.6 It is usually irreversible and if not adequately managed, its late complications can result in reduced life expectancy and considerable uptake of health resources. 2.2 Drug pharmacology 2.2.1 Treatment for asthma 2.2.1.1Beta-adrenoceptor agonists (e.g. salbutamol, terbutaline) These short-acting selective ÃŽ ²2 agonists (SABA) are the first line agents in the management of asthma and are also known as relievers. The selective ÃŽ ²2 agonists act on ÃŽ ²2 aderenoceptors on the bronchial smooth muscle to increase cyclic adenosine monophosphate (cAMP) leading to rapid bronchodilation and reversal of the bronchospasm associated with the early phase of asthmatic attack.5 Such treatment is very effective in relieving symptoms but does little for the underlying inflammatory nature of the disease. ÃŽ ²2 agonists should be initiated ‘when required as prolonged use may lead to receptor down regulation renders them less effective.5-6 Compared to SABA, long-acting beta-adrenoceptor agonists (e.g. salmeterol, formoterol) have slower rate of onset and their intrinsic lipophilic properties render them to be retained near the receptor for a prolonged period (12hours), which means that they cause prolonged bronchodilation. 2.2.1.2 Muscarinic receptor antagonists (e.g. ipratropium) Ipratropium blocks parasympathetic-mediated bronchoconstriction by competitively inhibiting muscarinic M3 receptors in bronchial smooth muscle.1,5-6 It has slower onset of action than ÃŽ ²2 agonists but last longer. 2.2.1.3 Inhaled corticosteroids (ICS; e.g. beclomethasone, budesonide) and oral prednisolone These agents are used to prevent asthmatic attacks by reducing airway inflmmation. They exert their anti-inflammatory actions via activation of intracellular receptors, leading to altered gene transcription. This results in decreased cytokine production and the synthesis of lipocortin leading to phospholipase A2 inhibition, and the inhibition of leukotriene and prostaglandins.5 Candidiasis occurs as common side effects with inhalation and systemic steroid effects such as adrenal suppression and osteoporosis, occur with high dose inhalation or oral dosing. 2.2.2 Treatment for pneumonia Antiobiotic treatment is appropriate with amoxicillin being used as first choice agent for mild, community-acquired infections. Depending on response and the strain of bacteria, other antibiotic agents can be used. Two groups of antibiotics which were given to the patient in this case scenario will be discussed here. 2.2.2.1 Cephalosporins (e.g. cefuroxime, ceftriaxone) Both ceftriaxone and cefuroxime are broad spectrum bactericidal antibiotics belong to cephalosporins group. They inhibit the synthesis of bacterial cell wall by binding to specific penicillin-binding proteins and ultimately leading to cell lysis. Second generation cefuroxime is beta-lactamase resistant and active against Gram-negative bacteria such as Haemophilus influenzae and Klebsiella pneumoniae. Being third generation cephalosporin, ceftriaxone display high beta–lactamase resistance and enhanced activity against Gram-negative pathogens (including Pseudomonas Aeruginosa), but it has relatively poor activity against Gram-positive organisms and anaerobes.1,5-6 2.2.2.2 Maclolides (e.g. azithromycin, erythromycin, clarithromycin) Maclolides prevent protein synthesis by inhibiting the translocation movement of the bacterial ribosome along the mRNA, resulting in bacteriostatic actions. Azithromycin has slightly less activity than erythromycin against Gram-positive organisms but possesses enhanced activity against Gram-negative bacteria including Haemophilus influenza. 2.2.3 Treatment for chronic cardiac failure 2.2.3.1 Loop diuretics (e.g. furosemide) Diuretics are the mainstay of the management of heart failure and provide rapid symptomatic relief of pulmonary and peripheral oedemia.5,6,9 Loop diuretics are indicated in majority of symptomatic patients and they work by inhibiting Na+/K+/2Cl- transporter in the ascending limb of the loop of Henle, inhibiting the establishment of a hyperosmotic interstitium and thus reducing the production of concentrated urine in kidney, leading to profuse dieresis.5-6 2.2.3.2 Angiotensin II receptor antagonists (e.g. losartan, candesartan, valsartan) These agents block the action of angiotensin II at the AT1 receptor, which will also reduce the stimulation of aldosterone release. Therefore AT1 receptor antagonists can be used as an alternative in patients suffering from a cough secondary to ACE inhibitors. 2.2.4 Treatment for Type II diabetes mellitus 2.2.4.1 Sulphonylureas (e.g. Gliclazide, glibenclamide, glipizide) The sulphonylureas have two main actions: increase basal and stimulated insulin secretion and reduce peripheral resistance to insulin action. They bind to receptors associated with voltage dependent KATP channels on the surface of pancreatic beta cell, causing channel closure which facilitates calcium entry into the cell and leads to insulin release. Sulphonylureas are considered in Type II diabetes patients who are intolerant to metformin, not contraindicated and not overweight. 2.2.4.2 Thiazolidinediones (e.g. rosiglitazone, pioglitazone) These new agents are ‘insulin sensitisers which act as nuclear peroxisome proliferator-activated receptor-gamma (PPAR-ÃŽ ³) agonist. They work by enhancing insulin action and promoting glucose utilization in peripheral tissue, and so reduce insulin resistance. Thiazolidinediones is known to be associated with oedema and increased cardiovascular risks, therefore these agents should be avoided in patients with heart failure.1,4,6 3.0 EVIDENCE FORTREATMENT OF CONDITIONS 3.1 Asthma 3.1.1 Evidence for the use of oral prednisolone and IV hydrocortisone in the management of AEBA There are mounting evidences suggesting that systemic corticosteroids effectively influence the airway oedema and mucus plugging associated with acute asthma by suppressing the components of inflammation, including the release of adhesion molecules, airway permeability and production of cytokines.10-12 A randomised trial involving 88 patients (aged 15-70years) with AEBA reported the significant efficacy of oral prednisolone (40mg daily for 7 days) in improving FEV1 and FVC at values of 68 ±45.3% and 53.4 ±46.5% respectively (P=0.04) in prednisolone-treated group.13 A Cochrane meta-analysis involving six trials recruiting 374 acute asthmatic exacerbation patients determined the early use of systemic corticosteroids significantly reduced the number of relapses to additional care, hospitalisation and use of short-acting ÃŽ ²2-agonist without increasing side effects, regardless of the routes of administration studied (oral/intramuscular/intravenous) and choice of agents.14 3.1.2 Evidence for the use of inhaled ipratropium bromide in the management of AEBA A double-blind, randomised controlled trials recruiting 180 patients with AEBA admitted to emergency department showed that ipratropium had beneficial effects in improving pulmonary function, with a 20.5% increment in PEF (p=0.02) and a 48.1% greater improvements in FEV1 (p=0.0001) compared to those given ÃŽ ²2-agonists alone. Ipratropium also demonstrated a 49% reduction in the risk of hospital admission.15 A more recent meta-analysis incorporating thirty-two double-blind, randomised controlled trials including 3611 patients with moderate to severe exacerbations of asthma also showed the benefits of combination treatment of nebuliser ÃŽ ²2-agonists and anti-muscarinic in reducing hospital admissions (relative risk 0.68,p=0.002) and in producing a significant increase in lung function parameters in AEBA patients (standard mean difference -0.36, p=0.00001).16 Another pooled analysis of three multicenter, double-blind, randomised controlled studies also showed that combination therapy of ipratropium bromide and salbutamol for the treatment of AEBA had decreased risk of the need for additional treatment (relative risk=0.92), asthma exacerbation (relative risk=0.84) and hospitalisation (relative risk=0.80).17 3.1.3 Evidence for addition of LABA to ICS in the management of asthma Symbicort Maintenance and Reliever Therapy (SMART) studies demonstrated the combined use of formoterol/budesonide contributes to a greater reduction in risks of exacerbations, improved lungs performance and better control of asthma than high dose of ICS with SABA.18-22 These studies also reported the advantage of this approach in terms of patient compliance as it allows the use of single inhaler for both rescue and controller therapy, and reductions in healthcare costs.18-22 A large double-blind, randomised trial reported that there was a significant 21-39% reduction of severe exacerbations in asthmatic patients treated with SMART therapy compared with high dose budesonide plus SABA.23 A meta-analysis involving 30 trials with 9509 patients showed that the use of combination inhaler (formoterol/beclomethasone 400mcg) resulted in greater improvement in FEV1, in the use of rescue SABA and in the symptom-free days compared to a higher dose of ICS (800-1000mcg/day).24 Another double-blind randomised trial investigating the effect of combination budesonide and formoterol as reliever therapy for 3394 patients who were assigned budesonide plus formoterol for maintenance therapy showed that the time to first severe exacerbation was significantly longer in as needed budesonide/formoterol group compared to as needed terbutaline group (p=0.0051). The other finding of the study is the significant lower rate of severe exacerbation for as needed budesonide/formoterol versus as needed terbutaline group (0.19 vs 0.37, p 3.2 Community-acquired pneumonia 3.2.1 Evidence use of combination therapy of second and/or third generation cephalosporins and macrolide in the management of pneumonia A multicenter, randomised trial investigated the efficacy of IV ceftriaxone 2g for 1 day followed by oral cefuroxime 500mg bd in the adult pneumonia treatment. The sequential therapy in combination with a macrolide achieved 90% of clinical success, 85% of overall bacteriologic clearance with 100% eradication of S.pneumoniae after 5-7days of treatment.27 An open label, prospective study involving 603 patients demonstrated that adding azithromycin (500mg od for 3days) to IV ceftriaxone 1g/day in the treatment of community-acquired pneumonia resulted in shorter hospital stay (7.3days vs 9.4days) and a significant lower mortality rate (3.7% vs 7.3%) than adding clarithromycin.28 Lack of randomisation and no blinding of evaluators may become the major limitations of this study; however the effectiveness of macrolide in addition to cephalosporins empirical therapy in treating pneumonia is unquestionable. 3.3 Chronic heart failure 3.3.1 Evidence use of loop diuretic in the management of chronic heart failure (CHF) A meta-analysis of 18 randomised controlled trials concluded that diuretics significantly lowered the mortality rate (odds ratio (OR) 0.25, P=0.03) and reduced hospital admissions for worsening heart failure (OR 0.31, P=0.001) in patients with CHF compared to placebo.29 Compared to active control, diuretics significantly improved exercise capacity in CHF patients. (OR 0.37, P=0.007).29 A recent review reappraisaled the role of loop diuretics as first line treatment for CHF concluded that existing evidence of association of loop diuretics with rapid symptomatic relief and decreased mortality supporting the essential role of diuretics in the management of CHF.30 3.3.2 Evidence use of angiotensin II receptor antagonists in the management of CHF The Losartan Heart Failure Survival Study ELITE II, a double-blind, randomised controlled trial involved 3152 patients with NYHA class II-IV heart failure and ejection fraction ≠¤40% reported that there were no significant differences between losartan and enalapril groups in all cause mortality (11.7 vs 10.4% mean mortality rate). However, losartan